On Doctoring in the COVID-19 ICU
Authors: Traci N. Adams
Journal: Annals of Internal Medicine (2023)

On Being a DoctorJuly 2023On Doctoring in the COVID-19 ICUFREETraci N. Adams, MDTraci N. Adams, MDAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M23-1276 Audio Reading - “On Doctoring in the COVID-19 ICU” Audio. Virginia L. Hood, MD, a physician from the University of Vermont, reads “On Doctoring in the COVID-19 ICU” by Traci N. Adams, MD Your browser does not support the audio element. Audio player progress bar Step backward in current audio track Play current audio trackPause current audio track Step forward in current audio track Mute current audio trackUnmute current audio track 00:00/ SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Only a few weeks into the Delta surge at our county hospital, I had descended into a state of abject hopelessness. Wave upon wave of patients with COVID-19 again flooded our hospital, most of them having declined a vaccine that might have made this particular surge preventable. Defeated and overworked, I headed toward the room of a patient whose oxygen saturation had dropped on the ventilator. The respiratory therapist had increased the fraction of inspired oxygen on the ventilator to 100%, and the patient was not recovering; her saturation hovered around 84%.This patient was a young mother who had developed severe COVID-19 in late pregnancy and had been intubated upon delivery of the baby because of hypoxemia. As the mother of young children myself, I immediately felt especially invested in this patient—a line that I had carefully tried not to cross during a pandemic in which more than 60% of the patients whom I cared for had died. Holding back emotion, I started the familiar sequence of checking ventilator mechanics, doing a bedside ultrasound to check for pneumothorax, starting inhaled nitric oxide, calling for paralytics, and getting set up to place her in a prone position.Oxygen saturation 80%—Her oxygen saturation dropped. More staff entered the room, discussing the status of her newborn and the three other children she had at home. Meanwhile, I struggled to keep up the barrier that I was so accustomed to hiding behind. Early in the pandemic, elderly patients with substantial underlying health issues made up most of our ICU population. During the Delta surge, the patients were younger and healthier, often parents of young children. The division between me as physician and them as patients felt artificial. The only thing keeping me out of a hospital bed given my work-related exposures was a vaccine series that we hoped would hold up against the latest variant.Staring at this incredibly sick young mother brought back floods of emotion as I recalled the first few days in the hospital with my children as newborns, days that were filled with joy and utter exhaustion. However, this patient had not met her baby and was intubated and paralyzed; we were a long way from skin-to-skin time. Instead of being full of life, this patient was on the brink of death, with only our ICU staff and a number of probably inadequate interventions standing in her way.74%—As her oxygen saturation continued to fall, I felt tremendous pressure. If this patient died and left her four children as orphans, the weight of failing to save her would become unbearable. I was already so accustomed to flashbacks of difficult rooms and devastated families that I knew where I was headed. Although I would physically leave this room at the end of my shift, I would mentally be here for years. We began placing a bag valve mask on the patient, and the pace of activity in the room intensified.Despite receiving inhaled nitric oxide and paralytics, she had only worsened. We had seen this hundreds of times and lost countless patients in this exact sequence of events. I called out orders while our weary ICU team worked in tandem to place the patient in a prone position; our minds inevitably wandered to the number of patients we had lost in this same way, except this time we were losing a mother with a baby in the neonatal ICU. I activated the ECMO team and prayed that we would have a circuit available for her.60%—Despite the prone position, paralytics, inhaled nitric oxide, and bag valve mask, the patient continued to worsen. Our nursing staff panicked. I began to cry, knowing that I had done all I could and was forced to stand here and watch her die.50%—I recognized that the only N95 I would receive for the next 4 days was wet from my tears. I pictured her children at home, wondering when Mom will get back as my own kids often do when I am gone for a long day in the ICU. Then I pictured them devastated at their mother's funeral because I didn't think she would ever come home.40%—Despite the best efforts of our team, we were losing her. The pressure to get her back was palpable; however, we continued to wait on the ECMO team and had exhausted our options. I placed her in a supine position again and waited. There was nothing else I could do. I am accustomed to having a fight-or-flight response in these moments of chaos; yet, this time I was frozen, watching the monitor, hoping and praying for a better outcome than that of the patients who had come before her, feeling completely helpless.30%—I knew I would be endlessly haunted by images of her children.12%—The room stood in stunned silence. We were watching her die. My best wasn't good enough. We prepared to start compressions, and I gave epinephrine to help her plunging heart rate. For a moment, the ICU rooms that are often marked by the coordinated movements of a team that is calibrated for emergencies could only watch.12%—We stood around her bed in stunned silence. This felt like an eternity.30%, 40%, 50%, 65%—Her saturation began to improve. We had ECMO circuit available. While we placed a bag valve mask on the patient, a cannula was inserted for ECMO. She would probably survive; however, with our ECMO outcomes, it is unlikely that she will return to the life she had before. I don't think I will either.I was crushed by grief and anxiety throughout the pandemic as I encountered patients like this day after day for nearly 2 years. I did not know at the time whether to seek mental health support or whether my emotions were a normal response to seeing the volume and acuity of patients who overwhelmed our ICU while fearing for my safety and that of my family. I was told repeatedly to seek support if I needed it, but how could I know whether I needed help? What is a normal response to unspeakable tragedy? I would never manage my own physical health conditions, so why was I left to manage my own emotional and mental health?Since recovering from the pandemic, I have learned that psychological distress, like COVID-19, is universal among those with substantial exposure to the virus and that only a subset of those experiencing such a significant stressor will develop diagnosable psychopathology. I have learned that I should have sought mental health support sooner because distress—although a normative response—can be debilitating and supportive interventions can help to lessen its impact.The current pandemic may be over, but the next one is coming. As we prepare for the next pandemic, we should learn from our mistakes. More than 40% of frontline workers had positive results when screened for generalized anxiety disorder or major depressive disorder during the pandemic. Like I did, many of them do not know when to seek help, so we must be proactive in offering it. We must destigmatize mental health and integrate mental health support for frontline workers into future pandemic response plans and postpandemic recovery. Comments0 CommentsSign In to Submit A Comment Eileen D. Barrett; Cynthia D. SmithInstitute for Healthcare Improvement; American College of Physicians19 July 2023 Destigmatizing physicians seeking mental health care We read with interest and appreciation Dr Adams’ piece “On Doctoring in the COVID-19 ICU,” and were struck by her honesty and vulnerability in writing this powerful and timely essay.(1) We, too, continue to be concerned about the mental health consequences of the pandemic - including mood disorders as well as conditions not generally medically treated such as moral distress and moral injury. We fully agree with her call for destigmatizing mental health diagnoses and mental health care. In response to the types of challenges to clinicians’ mental health emblematic of what Dr Adams describes, the American College of Physicians developed an Emotional Support hub (https://www.acponline.org/practice-resources/physician-well-being-and-professional-fulfillment/im-emotional-support-hub) that features vetted peer support and counseling resources for physicians, and a collection of short, practical videos to help physicians constructively address their emotions. The hub includes a library of other resources to help both individuals and organizations better address clinician mental health challenges. We also believe there is an urgent need for leaders across medicine and our communities to decrease the threats to clinicians’ mental health and help overcome barriers to physicians seeking mental health care. Many physicians fear seeking mental health care because they are afraid it will affect their ability to get or maintain their license and hospital privileges. One meaningful change to reduce barriers to physicians seeking mental health care is to revise medical credentialing and licensing applications to not stigmatize mental health. To support physicians doing this advocacy, ACP has developed a toolkit to assist physicians and medical students in this advocacy (https://www.acponline.org/practice-resources/physician-well-being-and-professional-fulfillment/advocacy-toolkit-modernizing-license-and-credentialing-applications-to-not-stigmatize-mental-health). We encourage physicians to engage in this advocacy while they work more broadly to support access to mental health care across settings and throughout their careers to ensure that physicians will continue to deliver care when patients need us most. (2) References 1. Adams, TN. On Doctoring in the COVID-19 ICU. Ann Intern Med. [Epub 13 June 2023]. doi:10.7326/M23-1276 2. Barrett, E, Hingle, ST, Smith, CD, et al. Getting Through COVID-19: Keeping Clinicians in the Workforce. Ann Intern Med.2021;174:1614-1615. [Epub 28 September 2021]. doi:10.7326/M21-3381 Author, Article, and Disclosure InformationAuthors: Traci N. Adams, MDCorresponding Author: Traci N. Adams, MD, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75219; e-mail, traci.[email protected]edu.This article was published at Annals.org on 13 June 2023. PreviousarticleNextarticle Advertisement Audio Reading - “On Doctoring in the COVID-19 ICU” Audio. Virginia L. Hood, MD, a physician from the University of Vermont, reads “On Doctoring in the COVID-19 ICU” by Traci N. Adams, MD Your browser does not support the audio element. Audio player progress bar Step backward in current audio track Play current audio trackPause current audio track Step forward in current audio track Mute current audio trackUnmute current audio track 00:00/ FiguresReferencesRelatedDetails Metrics Current IssueJuly 2023Volume 176, Issue 7Page: 1007-1008 ePublished: 13 June 2023 Issue Published: July 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...